PHYSICAL DIAGNOSIS THE PULMONARY EXAM
PHYSICAL DIAGNOSIS THE PULMONARY EXAM
WHAT SHOULD WE KNOW ABOUT THE EXAMINATION OF THE CHEST?
• LANDMARKS• PERTINENT VOCABULARY • SYMPTOMS• SIGNS• HOW TO PERFORM AN EXAM• HOW TO PRESENT THE INFORMATION • HOW TO FORMULATE A DIFFERENTIAL
DIAGNOSIS
IMPORTANT TOPOGRAPHY OF THE CHEST
TOPOGRAPHY OF THE BACK
LOOK AT THE PATIENT• RESPIRATORY
DISTRESS• ANXIOUS• CLUTCHING• ACCESSORY MUSCLES• CYANOSIS• GASPING• STRIDOR• CLUBBING
TYPES OF BODY HABITUS
WHAT IS A BARRELL CHEST?
• THORACIC INDEX – RATIO OF THE ANTERIORPOSTERIOR TO LATERAL DIAMETER NORMAL 0.70 – 0.75 IN ADULTS - >0.9 IS CONSIDERED ABNORMAL
• NORMALS - ILLUSION• COPD
AM J MED 25:13-22,1958
PURSED – LIPS BREATHING
• COPD – DECREASES DYSPNEA• DECREASES RR• INCREASES TIDAL VOLUME• DECREASES WORK OF
BREATHINGCHEST 101:75-78, 1992
WHITE NOISE (NOISY BREATHING)
• THIS NOISE CAN BE HEARD AT THE BEDSIDE WITHOUT THE STETHOSCOPE
• LACKS A MUSICAL PITCH • AIR TURBULENCE CAUSED BY NARROWED
AIRWAYS• CHRONIC BRONCHITIS
CHEST 73:399-412, 1978
RESPIRATORY ALTERNANS
• NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION
• PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES
• IMPENDING MUSCLE FATIGUE
DO NOT FORGET THE TRACHEA• TRACHEAL DEVIATION
• AUSCULTATE - STRIDOR
• TRACHEAL TUG (OLIVERS SIGN) – DOWNWARD DISPLACEMENT OF THE CRICOID CARTILAGE WITH VENTRICULAR CONTRACTION – OBSERVED IN PATIENTS WITH AN AORTIC ARCH ANEURYSM
• TRACHEAL TUG (CAMPBELL’S SIGN) – DOWNWARD DISPACEMENT OF THE THYROID CARTILAGE DURING INSPIRATION – SEEN IN PATIENTS WITH COPD
ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST
BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA
CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL
KUSSMAULS – METABOLIC ACIDOSIS
HOOVERS SIGN
• COPD• IN COPD THE DIAPHRAGM MAY BE
FLATTENED, DURING THE INSPIRATORY PHASE OF A BREATH THE RIBS ARE PULLED INWARD AND MEDIALLY RATHER THAN OUTWARD AND LATERALLY
THORACIC EXPANSION
• ASYMETRY IN EXPANSION OF THE THORAX CAN BE DETECTED DURING INSPECTION OF THE CHEST
• DURING PROMPTED INHALATION OBSERVE THE MOVEMENT OF THE THORAX
• PLEURAL EFFUSION, PNEUMOTHORAX
COPD
PINK PUFFERS BLUE BLOATERS
THORAX 38:595-600, 1983
DAHL’S SIGN
NICOTINE STAINS
SMOKERS FACE
BLUE BLOATER
PALPATION
• FEELING WITH THE HAND – FINGERTIPS• TEXTURES• DIMENSIONS• CONSISTENCY• TEMPERATURE• EVENTS
PERCUSSION
TWO TECHNIQUES• DIRECT – BLOW LANDS DIRECTLY ON THE
CHEST• INDIRECT – PLESSIMETER - USUALLY THE
MIDDLE FINGERTHREE TYPES
• COMPARATIVE• TOPOGRAPHIC• AUSCULATORY
DISEASE A MONTH 41:643-692,1995
METHODS OF PERCUSSION
DIRECT INDIRECTDISEASE A MONTH 41;643-692:1995
PERCUSSION SOUNDS
• TYMPANY – HEARD OVER THE ABDOMEN
• RESONANCE – HEARD OVER NORMAL LUNG
• DULLNESS – HEARD OVER LIVER OR THIGH
AUSCULTATORY PERCUSSION
METHODTHE STETHOSCOPE IS PLACED OVER THE POSTERIOR CHEST WALL, THE CLINICIAN THEN TAPS LIGHTLY OVER THE MANUBRIUM, EQUIVALENT SOUNDS SHOULD BE HEARD OVER CORRESPONDING AREAS OF THE LUNG. ASYMETRY SUGGESTS DISEASE.
AUSCULTATORY PERCUSSION
MANGIONE PHYSICAL DIAGNOSIS SECRETS 2000
TOPOGRAPHIC PERCUSSION
METHODTRANSITION POINT BETWEEN DULLNESS AND RESONANCE AT FULL INSPIRATION AND EXPIRATION
DIAPHRAGMATIC EXCURSION IS THE DISTANCE BETWEEN THESE TWO POINTS
NORMAL 3 – 6 CM
LONG FORGOTTEN PERCUSSION TERMS
• SKODAIC RESONANCE – HYPERRESONANT SOUND GENERATED BY PERCUSSION OF THE CHEST ABOVE A PLEURAL EFFUSION
• GROCCO’S TRIANGLE – RIGHT - ANGLED TRIANGLE OF DULLNESS FOUND OVER THE POSTERIOR REGION OF THE CHEST OPPOSITE A LARGE PLEURAL EFFUSION
DISEASE A MONTH 41:643-692, 1995
GROCCO’S TRIANGLE
DISEASE A MONTH 41;643-692:1995
MAIN SYMPTOMS OF PULMONARY DISEASE
• COUGH• DYSPNEA• HEMOPTYSIS• CHEST PAIN – PLEURITIC• WHEEZING• CYANOSIS• SPUTUM PRODUCTION
WHAT QUESTIONS SHOULD BE ASKED WHEN PRESENTED WITH A SPECIFIC
SYMPTOM? COUGH
• QUALITY• QUANTITY• CHRONOLOGY• SETTING• AGGRAVATING FACTORS• ALLEVIATING FACTORS• ASSOCIATED MANIFESTATIONS• LOCATION
ALWAYS DESCRIBE THE COUGH
• PRODUCTIVE – NONPRODUCTIVE• ACUTE – CHRONIC• TIME OF DAY• PRECIPITANTS – RELIEF• BLOODY – NON BLOODY• BARKING – HACKY
WHEEZING
• ASTHMA• BRONCHITIS• VOCAL CORD
DYSFUNCTION• FOREIGN BODY
ASPIRATION• INFECTIONS – CROUP
LARYNGITIS
• CONGESTIVE HEART FAILURE
• COPD• FORCED EXPIRATION
IN NORMAL SUBJECTS• CYSTIC FIBROSIS
NOT ALL THAT WHEEZES IS ASTHMA
THE NUMEROUS ETIOLOGIES OF CHEST PAIN
• PLEURITIC – PARIETAL PLEURA – SHARP STABBING – INSPIRATION
• ESOPHAGEAL – REFLUX• CARDIAC – MYOCARDIAL INFARCTION• GALL BLADDER – CHOLECYSTITIS• CHEST WALL – COSTOCHONDRITIS• GREAT VESSELS – DISSECTION• PULMONARY - PNEUMOTHORAX
THE PNEA’S
• DYSPNEA – SOB - IS NOT THE SAME AS TACHYPNEA - RR > 25 BR/MIN
• BRADYPNEA - RR< 8 BR/MIN• PND - PAROXYSMAL NOCTURNAL DYSPNEA
SUDDEN ONSET OF SOB DURING SLEEP• ORTHOPNEA – SOB LYING FLAT• PLATYPNEA – SOB SITTING UP AND BETTER LYING
FLAT• TREPOPNEA – SHORTNESS OF BREATH IN ONE
LATERAL DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE
SPUTUM - WHAT ARE ITS CHARACTERISTICS ?
• YELLOW – GREEN• RUSTY• CURRANT JELLY• PINK – BLOOD TINGED• FROTHY• BLOODY• SMELL – FOUL?
HEMOPTYSIS REQUIRES CAREFUL QUESTIONING
• THIS SYMPTOM USUALLY DENOTES A SERIOUS ILLNESS. TB, TUMOR, BRONCHIECSTASIS, PE, CARDIAC DISEASE
• THE PATIENT SHOULD BE QUESTIONED CAREFULLY REGARDING HOW MUCH, FREQUENCY WEIGHT LOSS ETC.
CLUES TO DIFFERENTIATING HEMOPTYSIS FROM HEMATEMESIS
HEMOPTYSISCOUGHFROTHYCOLOR- BRIGHT REDPUSDYSPNEACARDIAC DISEASE
HEMATEMESISNAUSEA – VOMITINGNOT FROTHYCOFFEE GROUNDSFOODNAUSEAGI DISEASE
CYANOSIS
• PERIPHERAL – HANDS, FEET – WARMING DECREASES CYANOSIS – DECREASED CARDIAC OUTPUT
• CENTRAL- LIPS, TONGUE,SUBLINGUAL - RIGHT TO LEFT SHUNTS
• PSEUDOCYANOSIS – BLUE PIGMENTS IN SKIN -AMIODARONE
CRIT CARE NURS 13:66-72, 1993
CLUBBING• PAINLESS – FINGERNAILS CURVED AND
WARM• ENLARGEMENT OF THE CONNECTIVE
TISSUES IN THE TERMINAL PHALANGES OF THE FINGERS >TOES
• HEREDITARY• DISEASE – INTERSTITIAL FIBROSIS, TUMOR,
BRONCHIECSTASIS, HEART DISEASE,ENDOCARDITIS
• OCCASIONALLY ASSOCIATED WITH HYPERTROPHIC OSTEOARTHROPATHY
LOVIBOND’S ANGLE – THE ANGLE BETWEEN THE BASE OF THE NAIL AND SURROUNDING SKIN.
CLIN CHEST MED 8:287-298,1987
CLUBBING
INTERPHALANGEAL DEPTH IS THE RATIO OF THE DIGITS DEPTH MEASURED AT B DIVIDED BY THAT AT A. O.9 normal 1.2 CLUBBED A RATIO > 1 INDICATES CLUBBING (B-distal phalangeal depth A- interphalangeal joint depth)
HYPONYCHIAL ANGLE IS THE ANGLE W XY. AN ANGLE > 190 DEGREES INDICATES CLUBBING. 185 DEGREES NORMAL – 200 DEGREES CLUBBED
CLUBBING
SCHAMROTH’S SIGN – LOSS OF THE SUBUNGUAL ANGLE
CLIN CHEST MED 8:287-298,1987
CLUBBING
LUNG SOUNDS
BREATH SOUNDS ADVENTITIOUS
BREATH SOUNDS• VESICULAR – NORMAL BREATH SOUNDS - SITE OF
PRODUCTION THE ALVEOLI
• TRACHEAL – TUBULAR – LIKE BLOWING AIR THROUGH A HOLLOW TUBE – PHYSIOLOGIC
• BRONCHIAL – TUBULAR - ALWAYS PATHOLOGIC WHEN THEY OCCUR OVER POSTERIOR OR LATERAL CHEST WALL
• BRONCHOVESICULAR – CHARACTERISTICS OF BOTH VESICULAR AND TUBULAR – DO THEY EXIST?
• ADVENTITOUS – EXTRA SOUNDS
BREATH SOUNDS
TIMING
CHARACTERISTIC TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY VERY LOUD LOUD MODERATE LOW
I:E RATIO 1:1 1:3 1:1 3:1
ADVENTITIOUS SOUNDS• THESE ARE SOUNDS HEARD DURING
AUSCULTATION OTHER THAN BREATH SOUNDS OR VOCAL RESONANCE
• NOMENCLATURE – HAS BEEN CONFUSING• CRACKLES – DISCONTINUOUS SOUNDS• WHEEZES AND RHONCHI – CONTINUOUS
SOUNDS
ATS NEWS 3:5-6,1977
SEMIN RESPIR MED 6:210-219,1985
ADVENTITIOUS LUNG SOUNDS (BRUITS ETRANGERS – FOREIGN SOUNDS)
• WHEEZE – HIGH PITCHED• RHONCHI – LOW PITCHED• CRACKLE RALES - HAIR
VELCRO (FINE – COARSE) • PLEURAL RUBS – CREAKING LEATHER• STRIDOR
EARLY AND MID INSPIRATORY LATE INSPIRATORY
COARSE FINE
LOW PITCHED HIGH PITCHED
CLEAR WITH COUGHING DO NOT CLEAR WITH COUGHING
SCANTY PROFUSE
GRAVITY IN DEPENDENT GRAVITY DEPENDENT
TRANSMITTED TO THE MOUTH POORLY TRANSMITTED TO THE MOUTH
ASSOCIATED WITH OBSTRUCTION
ASSOCIATED WITH RESTRICTION
CRACKLES
BRONCHITIS-BRONCHIECSTASIS
INTERSTITIAL FIBROSIS -INTERSTITIAL EDEMA
FREMITUS = VIBRATION
TACTILE FREMITUS
• A THRILL OR VIBRATION WHICH IS FELT ON THE CLINICIANS HAND WHILE RESTING IT ON THE PATIENTS CHEST WALL AT T HE SAME TIME THE PATIENT SPEAKS. 99 – 1-2-3
• SYMETRY MAY BE SEEN IN NORMALS• ASYMETRY – IS ABNORMAL
TACTILE FREMITUS
• PNEUMONIA • PNEUMOTHORAX• PLEURAL EFFUSION• COPD• FAT
INCREASED DECREASED
VOCAL FREMITUS
• THE PATIENTS VOICE IS HEARD THROUGH A STETHOSCOPE PLACED ON THE PATIENTS CHEST – NORMALLY THE SOUNDS ARE INDISTINCT
• ABNORMALITIES – BRONCHOPHONY, PECTORILOQUY, EGOPHONY
• CONSOLIDATION
VOCAL FREMITUS
• BRONCHOPHONY – SOUND OF THE BRONCHI –SOUND MUCH LOUDER THAN NORMAL - WORDS INDISTINCT
• PECTORILOQUY – VOICE OF THE CHEST –WHISPER – WORDS INDISTINCT
• EGOPHONY – VOICE OF THE GOAT – BLEATING - E – A CHANGES – COMPARE SIDE TO SIDE
• REMEMBER - ALL SUGGEST CONSOLIDATION OF THE LUNG
PUTTING IT ALL TOGETHER
• PNEUMONIA
• PNEUMOTHORAX
• PLEURAL EFFUSION
• ASTHMA
PNEUMONIA
INSPECTION – SPLINTING
PALPATION – INCREASED FREMITUS
PERCUSSION – DULL
AUSCULTATION – BRONCHIAL BREATH SOUNDS, CRACKLES, EGOPHONY, PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTUCTION MAY MASK THE USUAL PHYSICAL FINDINGS OF PNEUMONIA
PNEUMONIA
PLEURAL EFFUSION
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – FLAT, DULL
AUSCULTATION – ABSENT OVER EFFUSION, BRONCHIAL IMMEDIATELY ABOVE EFFUSION, RUB OCCASIONALLY
PLEURAL EFFUSION
PNEUMOTHORAX
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – TYMPANIC
AUSCULTATION – ABSENT BREATH SOUNDS
PNEUMOTHORAX
ASTHMA
INSPECTION – ACCESSORY MUSCLES, UNCOMFORTABLE
PALPATION – DECREASED FREMITUS
PERCUSSION – HYPERRESONANCE
AUSCULTATION – PROLONGED INSPIRATORY AND EXPIRATORY WHEEZES